This is quite relevant to a large number of people since depression is quite prevalent in the general population. It is estimated that 5.8% of men and 9.5% of women will experience a depression e episode in a 12 month period. The lifetime incidence of depression has been estimated at more than 16% in the general population.

This research study was by Dr. An Pan  and four colleagues from the Harvard School of Public Health and Harvard Medical School. The research was a meta-analysis and a systematic review which meant that the authors studied research of many studies on this subject The ended up looking at 28 prospective cohort studies comprising 317,540 participants which reported 8478 stroke cases during a follow-up period ranging from 2-29 years.

Their scientific analysis of the data demonstrated that depression is associated with a significantly increased risk of developing stroke. They also found a positive association of depression with a fatal stroke.

The authors discussed a variety of mechanisms which depression may contribute to stroke. Depression has known neuroendocrine effects. For example t there is a dysregulation of HPA axis ( hypothalamic-pituitary-adrencortical axis which can cause high blood pressure. It has been shown that depression effects platelets and leads to  dysfunction which causes abnormalities in the clotting mechanism. There are also abnormalities in the immune and inflammation systems which could influence stroke risk..

Depression is associated with poor health behaviors such as smoking, physical inactivity, poor diet, lack of medication compliance and obesity, all of which may contribute to stroke.

Depression has already been associated with coronary heart disease, diabetes and hypertension. (See an earlier blog on depression and heart disease as well as another blog which raised the question whether people with depression should be taking aspirin to prevent heart attacks).

The data from the recent JAMA study also suggested that it is possible that antidepressant medication may be associated with stroke risk but this may be a false impression since medication use can be a marker of depression severity and many of the studies that the authors looked at lacked information on dose and duration of medication use.

There are some limitations of this study and the findings don’t prove 100% that depression causes stroke. I would imagine that it is conceivable that the genetic markers for stroke and depression could be located in close proximity leading to such impression of this effect. However even if there is no causative effect (  although I believe the research strongly suggest one ), the association of these conditions clearly calls out for great attention being paid to this association. There is an opportunity for doctors who see patients who are at a high risk for stroke to be referred for treatment of depression. Also patients who are being treated for depression should be encouraged to be seek medical attention and assistance in reducing all the other risk factors for stroke whenever possible.

Depression is a serious condition and is very treatable. Treatment works! Patients who have depression should be treated whether or not they are at a higher risk for stroke and other diseases.

Paul Krugman

Recently Paul Krugman wrote an interesting piece in the NY Times titled, Patients Are Not Consumers . In it he wonders what has gone wrong with us if receiving health care is like buying a car?

While he did not discuss specifically the treatment of mental illness and psychotherapy, those of us in this field have similar concerns.

Thinking about this article sent me to the dictionary (Webster’s Unabridged 20^th Century-2nd Edition) to look up a couple of words that are used in this debate.

Consumer– A person who uses goods or services to satisfy his need rather than to resell them or produce other goods with them.

Client– A dependent one under protection or patronage of another person or company in its relationship to a lawyer, accountant etc, engaged to act on its behalf, loosely, a customer.

Patient– A person receiving care or treatment; especially, a person under the care of a doctor; as the physician visits his patient morning and evening.

It is wonderful to observe how inapprehensive those patients are of their disease- Blackmore

Provider– One who provides, furnishes or supplies; one who procures what is wanted

Care giver– (There is no single word as such)

Rather than further try to analyze or argue why and how these words should be used, I would like to present a few real situations and ask you to consider which words seem most appropriate :

1-Mrs. Jones as you know I check blood levels of Lithium and do other routine blood tests on my (choose one – patients, clients , or consumers) and I  have just received the results back. While the lithium level is right where we want it, I do note that your TSH is high which indicates that you may have a hypothyroid condition which could be contributing to your recent depressive symptoms. I would like to call your (choose one – primary care provider, medical care giver, health care provider, primary care physician) and I would like you to make an appointment with her.

2-(Phone call) Is this the emergency room (choose one – provider, care giver,  physician)? My (choose one- consumer, client,  patient) has just informed me that she took an overdose of tranquilizers and antidepressants which I have been prescribing for her and I have arranged for an ambulance to bring her to the hospital.

3-It appears that you are jealous of the other (choose one – consumers, clients, patients) in the waiting room as you were jealous of your siblings and you want to leave me as you left your other (choose one : providers, caregivers,  therapists)

I understand that some of the words with which many of us are uncomfortable  have come from the people who are trying to develop healthcare systems for large numbers of people. For  them, such words as providers, caregivers, consumers or clients may better suit the concepts  which they are dealing with in the abstract. One might argue that the meaning of words may change but if one is clear in regard to their own identity, perhaps it isn’t a big deal if a different word is used. If I have established a doctor-patient relationship with a patient and I am clear as to my code of ethics why should I get upset if a patient or an insurance company calls me a provider ? The problem is that there is a blurring of the expectations between  a casual sale of an automobile to a consumer and the expectation of a physician or other health care professional  who is entrusted with the care of a patient.

There is a special bond that physicians have with patients which has its origin with the Hippocratic Oath. It has come to mean a selfless dedication to doing everything in one’s power to help the person who has trusted us with their healthcare. There may be obstacles and complications related to third party payers, treatment being shared by multiple specialties and disciplines, patients being guided by information from the Internet etc, but we still view the patient as someone we owe a special obligation to do our absolute best to assist. The objective and subjective meaning of the words provider, client, consumer, etc. do not convey the relationship which we feel towards our patients and which they usually feel towards us . In the past many of our non-physician colleagues in the mental health profession also used this model and have a similar bond with their patients.

My generation of psychiatrists and other mental health professionals, I believe are clear in our  role and the expectations of our patients. However, it is somewhat more confusing for young people just out of training especially when they take positions in Mental Health Clinics where the newer terminology may be used. It may be easier for a young psychiatrist who has had some experience in medical school and during internship (PGY 1 year) where he or she has functioned in life and death situations.

Those experiences become the underpinning of how they will view the people that they will treat. Certainly that can become eroded if they are in an environment where other models are used. I also believe that it may be more difficult for young social workers and psychologists to appreciate the differences if they have only worked with these new terms during their training.

In ten years from now will this be a moot question?  Or will our attention to this debate now and the public’s desire for special relationships with the people who provide their health care treatment (physical and mental ) prevail in reality and in the terminology which we use?

I would welcome comment from anyone on this topic. I also am especially interested in the experience of our international readers of this blog (who make up about 50 % of the visitors to this site) Are there new words in other languages replacing doctor, physician and patient? Is this being discussed in other countries?

A case history *

An 82 year old Italian speaking grandmother with a very dedicated and loving large family was coming to the hospital three times a week to receive hemodialysis for kidney failure. This is a four or five hour process where tubes are attached to her blood vessels through a special connection called a fistula and her blood is run through a machine with a filter system to clean it of toxins since her kidneys are not functioning properly. She was viewed as having been depressed for approximately two years and frequently would be reluctant to come for her dialysis. She was on Prozac, an antidepressant, for about one year with no apparent change.

Recent Complication

Most recently the patient’s fistula clotted and there were no more readily available sites to reconnect the equipment. Surgery was recommended to create a new vascular site for the dialysis but the patient refused to go along with this procedure. The family explained that she had suffered enough  and now just wanted to stop the dialysis and peacefully pass away.

Psychiatric Consultation

The first psychiatrist who saw the patient interviewed her with the family as translator and also understood enough Italian to confirm that this was what the patient was requesting. There was no evidence of significant depression or overt psychosis. The family was very sad about this decision but felt strongly about respecting her wishes.

Second Opinion

Because of the finality of such a decision, it was not unusual to have a second psychiatrist see the patient and I was asked to see her. Rather than use the family as a translator or have them be present during the interview, I asked a nursing supervisor who spoke Italian to do this task.

The patient related well and showed a clear sensorium, very much aware of her surroundings and the situation. She said that she did not want to die and enjoyed being at home visiting with her grandchildren and watching television. She was not in significant discomfort. However she believed that her children believed it was time for her to move on. She wrongly thought that her medical care was a financial burden to her family. She also believed that family members who brought her for dialysis were taking valuable time away from their jobs and family. She even could give examples of things that they had said to confirm this. She believed that the proposed surgery to establish her dialysis site was very unusual and the doctors resented doing it . (Both of these ideas were not true).

Therefore she thought that the right thing to do was to refuse the procedure and peacefully die. She viewed her family as respecting her statement that she did not want dialysis as proof  that she was a burden to them.

The Resolution

I needed to do some sensitive delicate follow-up work with the patient and her family to get the patient to accept the surgical procedure and continue on dialysis. Once the family understood that the patient enjoyed her life and was not ready to die , they become very supportive and determined to help her in every way that they could.  The family arranged a rotating schedule of drivers for her dialysis that included the grandchildren, which proved to very gratifying for all those concerned.

It should be mentioned that there are patients who decide to go off dialysis and end their lives. Most hospitals have a process usually in conjunction with a Hospital Ethics Committee where this can take place.

*This Case history is based on a case report in a  a book that I wrote with Dr. Maria Tiamson-Kassab titled Practical Guidelines in Psychiatry- Psychosomatic Medicine published by Wolters Kluwer/Lippincott Williams & Wilkins  2^nd E dition (2009).

Additional Comments

In 1972 the US Congress passed legislation providing that Medicare would cover the costs of dialysis regardless of the age of the patient. An important part of the debate concerning this legislation was when an actual patient was put on dialysis in front of the Congressional Committee discussing this impending bill. The statistics on the prolongation of  lives in the United States because of the treatments now  available are quite dramatic. While most of these treatments are  done at dialysis centers, there are specific types of dialysis that allow it to be done at home with home dialysis or in an ongoing  continuous manner, known as Continuous Ambulatory Peritoneal Dialysis (CAPD) ,  while a person goes on with their usual activities  Many  people undergoing this treatment  have  been able to maintain a  very good quality of life. However, the time on dialysis has obviously altered people’s life styles and so have the medical complications that  can occur with renal disease and the various treatments for it. There are also psychological sequelae of this medical condition and treatment. Advances in renal transplantation have allowed many people to come off dialysis after receiving a kidney transplant from a cadaver or live donor ( often a close relative ) This situation is a major life event and has it’s own  medical and psychological implications. Many psychiatrists and other mental health specialists, particularly psychiatrists who are in the recently certified sub specialty field of Psychosomatic Medicine are interested in these issues. I look forward to discussing this topic  in future blogs.

Your comments are welcome.

“ Mrs. Jones, I feel that you are going to benefit greatly by taking antidepressant medication and I would like to start you on XYZ medicine. You should take it once per day . These are possible adverse effects…Most people do very well on it. I am going to give you a 10-day supply of medication and then we will see how things are going. Do you have any questions?”

Mrs. Jones, who has been anxious and depressed to start with, may have some additional anxiety about starting a new medication. She may feel hopeful that this doctor seems to understand her and believes that the medication ( plus any psychotherapy that is going to take place ) will give her relief from her suffering. She probably is pleased that she has been given a “gift”, the free medication sample.

The doctor is pleased. He or she has diagnosed the depression as one that should be helped by medication. While there were several excellent antidepressant medications, which could be prescribed, the one that he chose has had very good reviews in the literature and he has some samples to give to the patient. He is glad to see that she perked up when she received them and was pleased to be giving her the free starter dosage package.

The patient returns in a week to 10 days and while the depression most probably hasn’t fully lifted yet, if she is tolerating the medication reasonably well which most people do, he will write her a month supply of medication and continue the follow-up which may involve psychotherapy. ( He might even give her some additional starter packages if he had them on hand )

Is There Anything Wrong With This Story?

Many psychiatrists in my generation  were trained in this kind of an environment. It actually felt gratifying when working in clinics to give people in lower socio-economic groups free medication to start them off or medication to supplement their paid prescriptions which even a co-pay payment would be a burden. In fact , it almost seemed therapeutic to give any patient a free sample of medication even well off patients. When the SSRIs first came out, they  were understood to be superior choices for most people with much less side effects. There are no generic choices of this class of medication so a sample seemed better than nothing or better than the inferior older medication of the tricyclic type some of which did have a generic version.

Unfortunately, there is another view of what is going here. What the patient may view as a free starter package , the US pharmaceutical industry views as “Sampling Medications“ and it is one of the  most important components of their drug-marketing program. Over 50 % of money spent for marketing goes into sampling  It also has been shown that doctors are often willing to spend time with drug company sales representatives in order to obtain samples to give to their patients  Furthermore samples have been shown to cause significant increases in new prescriptions for new drugs being marketed.

The doctor in the above example may very well feel that he prescribed the best possible medication for the patient and maybe he did. The doctor may also feel that he has seen several pharmaceutical representatives and listened what they all had to say before taking the samples and then read some objective research . Maybe he didn’t even talk to the pharmaceutical representatives and the sampling process does not unduly influence him. Perhaps also this doctor saved some money for some of his patients who were feeling the financial crunch of the economy.

The emerging objective research suggests however  that sampling is having an influence on the practice of medicine quite different than this individual doctor and maybe other individual doctors perceive is happening

Most Samples Don’t Go to Uninsured and Low Income Patients.

Studies have shown that poor or uninsured patients are less likely than those with wealth or insurance to receive free drug samples.  In addition physicians, office staff and pharmaceutical sales representatives receive  many of the samples  intended for patient use.

Some states have laws that samples can only be used patients .

Samples Don’t Save People Money

Samples of course are not available for less expensive generic medications Samples are generally only available for newer brand name drugs. Research has shown that doctors who use samples tend to use more expensive drugs. Once a patient is started a particular drug and it is working, they will usually continue on it, often for long term

Doctors May Not Choose  Their First Choice Medication When Samples Are Available

One study showed that doctors who had samples for patients did not prescribe their usual first choice medication. In other words they were influenced by the availability of the samples to even choose one brand over another brand

Availability of Brand Name Samples Makes Prescription of  Generics Less Likely

Other research has showed that physicians were three times more likely to prescribe the usually cheaper generic medications to uninsured patients after drug samples were removed and no longer available to them . Therefore it does appear that prescribing patterns are correlated with samples that are available

Other Potential Problems with Samples

Samples are often not properly labeled for the individual patients. Therefore medication errors or misuse are more likely. The storage of samples may not be done properly as would be in a pharmacy. Maintaince temperature and elimination of outdated medication may not be as efficient.

A Word About Generic  Medications

The pharmaceutical companies develop new medications and patent them They deserve to profit from their research, development and marketing. This encourages them to develop still newer and better drugs.  After a period of what used to be 20 years and now is down to 12 years their patent expires. Other companies can now make  the exact medications know as the generic version. These versions can be offered for much less money since the market is now competitive. This topic  is much more complicated than this summary as mirror images or other versions  are patented with possible special advantages . There are claims and counter claims of generics not being bioequivalent or as safe as the original. We are talking about a multi billion-dollar industry.

How To Address the Sampling Issue

Many people would like the sampling of medications be completely eliminated from medical practice in the country today. I doubt that this is gong to happen. Even if it came about by being incorporated in the new healthcare legislation. I don’t think the billions of dollars that this program costs would be directed towards lowering medication costs or towards educating doctors about new drugs  or the value of generics.

Clinics and large practices are increasingly organizing their collection of samples to support patients who cannot afford medications. Having pharmaceutical companies contribute directly to such stockpiling and not have contributions of samples be related to discussion with doctors is thought by some people to be a good idea.

Particular attention needs to paid to the sampling of resident doctors ( doctors in training) who may be more susceptible to being influenced by such practices. Although sometimes it is the younger doctors who completely reject this practice on principle.

It behooves any physician who utilizes samples to consider whether they are being subtly influenced ( unconsciously,  if you wish ) to favor the high price drug over a less expensive drug that they don’t have a sample, especially a generic drug.

Good psychiatric technique would suggest that if samples are used, the doctor should discuss the pros and cons of using this medication and the potential long term costs of it .In fact the pros and cons of using a generic vs. new expensive brands should always be discussed in detail with the patient.

Adendum

On the same day that I published this blog, there was an article on the front page of the business section of the New York Times ( January 13th ) stating that a group of members of the House of Representatives plan to ask Congress to block business deals in which  they say makers of name-brand drugs directly or indirectly pay generic makers to delay competition from cheaper generic alternatives. It is reported that the  Federal Trade Commission has estimated that such deals currently cost American consumers  $3.5 billion a year. This is another illustration of the financial incentives to the pharmaceutical industry , whether  by sampling or such deals, to keep doctors and patients away from generic drugs.

Your comments on any aspect of this issue are very welcome.

About a year ago my wife and I relocated from New York to Southern California. After many months of remodeling our new home , building a home office and setting up my practice I thought we were  settled and I  was now a Californian. Then I experienced my first earthquake. It was a relatively mild one I am told. But for 15-20 seconds it was a little rock and roll in our new house. We had lived in San Francisco many years ago during my internship but I had forgotten what these shakes feel like and how helpless you actually are during these occasions.

Sorry Your Insurance Won’t Pay For Extra Medication

So not surprisingly, I was mobilized to action as people often are when they experience an episode of helplessness. I ran out and  bought flashlights , a crankable radio, picked up a months supply of water and a first aid kit. I even bought “museum putty”  a product I never heard of before which fastens objects on bookcases and shelves to prevent damage during a shake.  Then I went to my local pharmacy to be sure we had at least an extra  month supply of our prescription medications for our emergency kit.  By this I mean an extra month that would be in place even if the usual month supply or 90 day supply was running down. My pharmacist says sorry you are not authorized for such . Well of course I could get my physician to write it for me or being a licensed physician I could write the prescription myself. However the pharmacist informed me, of what I should have realized, that even if I had a prescription for an emergency supply of medication, my insurance prescription coverage wouldn’t pay for it. The same rules apply to online purchases.

People Can Run Out of Medication  During A Disaster

I am not a newcomer to the study  of disasters. I  had served on the Dimensions of Disasters Committee of the American Psychiatric Association.  For the past several years I have taught a course for psychiatrists at the annual meeting of the American Psychiatric Association  with a New Jersey psychiatrist Dr. Joe Napoli . I also edited a book in this area with Dr. Bob Ursano Chair of the Department of Psychiatry of the Uniformed Services School of Medicine . We taught the participants of our course about the common knowledge among disaster experts that the most frequently dispensed medication to people in the aftermath of a disaster is not a tranquilizer or a sleep medication but rather prescriptions for the everyday medications, which they take and now no longer have access to or have run out of them.

Just recently I read the position statement of the American Association for Geriatric Psychiatry about Disaster Preparedness  sent to me by Dr. Morty Potash, a psychiatrist from New Orleans . In it was mentioned the fact that during Hurricane  Katrina  more than 56% of the persons who went to the Astrodome for shelter, 5,846 persons, were older than  65 year of age. Similarly, access to needed prescription medications represented a significant problem. Obviously, it can also be a problem for people of every age. Furthermore, the most common visits to Houston  Texas Emergency Rooms by people displaced by Katrina were for refills of existing medications suggesting that the usual resources for refills were absent. It stands to reason that there is a possibility of medical offices  being made unavailable by the disaster, physician and staff being injured or predisposed caring for other victims.

A Reserve Supply of Medication is Needed

Patients will need to have at least a month supply of their medications. We are talking about  the common heart medications, blood pressure medications, thyroid , insulin and other hormonal treatment , antibiotics, medication for prostate and urinary  problems as well as cancer therapies and many less common types of treatment

Psychiatric patients will need access to their medications of course. Patients taking medication for panic disorder would be likely to have an exacerbation of attacks should they run out of medication and certainly the stress of an emergency situation would make this even more likely. Patients taking medication to stabilize a mood condition such as one of the bipolar mood disorders could decompensate as could a person with schizophrenia who no longer has access to antipsychotic medication . While it can take a few weeks, depression can reoccur after cessation of antidepressants.  The result of the return of serious depressive symptoms can be suicidal behavior . Research demonstrated that psychiatric medication among Manhattan residents following the World Trade Center Disaster increased.

As I mentioned, many people do get a 90 day supply of medication and may even have a prescription for three renewals .The ability of physicians to write prescriptions is regulated by the states with federal laws governing certain type of controlled medications. There may be some variations in different parts of the country . It appears to me that most states will not allow a full month supply of medication to be held on a continued basis ( with rotation if meds become outdated.) Also most if not all  insurance  plans do not allow or will not pay for  a renewal until a short time before the drugs run out which means that you can’t guarantee that you can put away a supply of medications for emergency planning.

It would seem logical that a physician should have the ability to write a prescription for an extra month supply of medication and provide instructions for rotations of the drug if there is concern about it being outdated. It also seems appropriate that insurance companies should pay for this extra supply of medication even though in most cases it won’t be used and will just be out there being rotated. ( I am sure the pharmaceutical companies won’t mind this situation.)

There Can Be Exceptions

It also is true that under some circumstances a physician may not want the patient to have more than a limited supply of a particular drug. This could be because the effects need to be evaluated before more meds are prescribed or perhaps because the physician may be concerned about potential addiction problems or even suicidal tendencies. In such situations the physician  properly might not write a prescription for extra medication  even if he or she were authorized to do so.

Can We Change the Regulations and Laws?

As a recent Past Speaker and therefore a member of the Assembly of the American Psychiatric Association I co-authored with several other psychiatrist including Dr. Napoli, mentioned above and Dr. Arshad Hussain from  Missouri who is  past Chair of the APA Committee on Dimensions of Disaster, a resolution to have the American Psychiatric Association to investigate this situation and advocate with other groups such the American Medical Association on the national level and State Medical Associations on the local level  so legislative regulations are altered to facilitate this aspect of disaster planning. This was approved by the Assembly in November in Washington D.C and I am hopeful that this organization will take up the advocacy with other interested parties mentioned above as well as with government agencies and.  insurance companies. I also spoke with my California State Assemblyman ( who happens to be my son ) who will look into this issue further in my state. These types of changes don’t occur quickly or easily.

Can You Survey Your Local Situation  ?

Although this weekly blog has only been up for a little more than two months we know that we are read in many states throughout the US as well as many countries. Can those of you who are iinterested in this issue check it out and determine if the average person can get an extra supply of medication for emergency preparedness where you live and would most insurance companies pay for it? Please send a comment on your findings to this blog ( below ). We will put it on within 12-24 hours. Perhaps we can get the data that will motivate those who make the laws and regulations. The power of the Internet can also help us get such information to the people who can make differences on  this issue both in the US and elsewhere. Lives could even be saved in the next disaster event.

Your Comments and Data on this Topic is Welcome

The  extramarital affair between Frank Lloyd Wright & Mamah Cheney

I belong to a book club and the selection we read a few months ago was Loving Frank by Nancy Horan

It is an historical novel based on the love affair of famed American architect Frank Lloyd Wright and a married woman Mamah Cheney. They met when Wright was asked by the young Cheney couple to design a home for them in Oak Park, Illinois, a suburb of Chicago in 1903.

The author appears to have impressively researched the material on the subjects of the novel as described in the afterword and in interviews with her. Whether she has accurately captured their inner thoughts, conflicts and all the circumstances of their relationship is not as important to me as is the discussion that she is stimulating about marriage, love, loyalty to children, the effect of divorce on children, feminism and the relationship between men and women. This is quite an accomplishment for a first novel.

The Affair

Mamah Cheney, college educated with a masters degree, writer, fluent in several languages, mother of two small kids, realizes she shouldn’t have married Edwin who is a nice enough devoted hardworking husband. She is now smitten with Frank Lloyd Wright, self centered, creative, brilliant architect who designs buildings to blend with nature. He also has small children and is married to Catherine whom he feels doesn’t understand his special qualities. Mamah and Frank, who appear to deeply appreciate one another, fall in love and go off together. Although it is difficult for her, Mamah is able to leave her children to her husband who cares for them with the help of a live- in single sister and a housekeeper. She and Frank live in Europe for awhile and eventually settle in Wisconsin where Frank designs their new residence called Taliesin (from the Welsh word meaning “shining brow” as it is  built into the brow of the hillside instead of on top of the hill). Wright is, of course, is known for his “organic architecture” Ultimately Mamah has some visits with her children but has essentially abandoned them for most of their early childhood. Frank visits his children periodically in Chicago but is basically out of his house living with Mamah in Wisconsin

One Lives But Once in The World

The story unfolds mostly through Mamah’s eyes and thoughts. The reader is not only swept up in the story but is given ample opportunity to identify with Mamah and the excitement of her life .She has clearly made a mistake in her decision to originally marry Edwin. She now sees the opportunity to rectify her big false step by living out a life in love with rich fulfillment in so many ways with Frank. The author’s empathy for her is quite palpable in the book as well as in the epigraph she chose for her novel from Goethe, “One lives but once in the world.” At the same time the main character in the book wonders about the decisions that she and Frank have made as well as the implications for their spouses and children. Many of her own ideas are honed and clarified as she meets Ellen Key a Swedish feminist, and agrees to translate her writings for American readers. While Mamah strongly agrees with just about everything Key asserts, she did have some qualms with her statement:  “The very legitimate right of a free love can never be acceptable if it is enjoyed at the expense of maternal love.”

Front Page Scandals

In the novel and apparently in reality, this affair was considered a front page scandal in the Chicago newspapers which of course had great impact on the participants. The criteria for a public airing of such an affair  may have changed in the past one hundred years. It now appears to have to be a popular movie or television star or a major politician but there is no shortage of such front page stories. Not too long ago a  TIME magazine feature story  Unfaithfully Yours examined the marriage of Mark Sanford, governor of South Carolina, and his wife Jenny, former senator and former  presidential hopeful John Edwards and his wife Elizabeth, former governor of NY Eliot Spitzer and his wife Silda  and reality TV parents of eight kids Kate and Jon Gosselin. The men in each of these high profile marriages chose to have extra-marital affairs with lesser known women.

Fulfilling Oneself vs. Impact on the Children

The writer of the TIME piece, Caitlin Flanagan, concludes that there is no other single force causing as much measurable hardship and human misery in this country as the collapse of marriage. She believes that  that it hurts children, reduces mothers’ financial security and it has landed with particular devastation on those who can bear it the least, the nation’s underclass. While the characters in the novel or the high profile people mentioned above don’t fit into this socioeconomic class, few would argue that the impact of divorce probably is magnified as you move down this ladder.

While empathizing with any woman’s legitimate wish to be happy and live a fulfilled life as she sees fit, let us keep our eye on the impact on the children. The book keeps returning to Mamah’s feelings and obligation to the children. This was a time before shared custodial arrangements or single mothers were common , let alone same sex parents. Our modern day  recent TIME article quotes a 1994 book  Growing up With A Single Parent by Sara McLanahan who studied effects of divorce on children from middle and upper income households.  She concluded that “children who grow up in a household with only one biological parent are worse off on average than children who grow up in a household with both of their biological parents regardless of the parents’ race or educational background.”

Views of Paulina Kernberg and Judith Wallerstein

Before I recently relocated to California, I lived and practiced in Westchester county a suburb of  New York City. One of my colleagues was the outstanding child psychiatrist and psychoanalyst Paulina Kernberg who wrote extensively on children and divorce.   She believed divorce, was the second worst trauma a child could undergo, exceeded only by the death of a parent. The psychological scars, she warned, lingered, and in many cases a child was better served living in a loveless or contentious marriage than shuttling between separate households.

Perhaps one of the most important recent books giving insight into the impact of divorce on children was The Unexpected Legacy of Divorce written by a renowned San Francisco psychologist Dr. Judith Wallerstein with Julia Lewis and Sandra Blakeslee. This was a 25 year study of a group of 131 children whose parents were all going through a divorce. She pointed out among other things that over time these now grown children who usually do not a have a model for a successful relationship have to figure out how to find loving partners and to become good protective parents. She also highlighted how the effect of divorce on a child may not appear until this child is in his or her late 20’s to early 40s. At this time they can have great fears of loss, conflict and betrayal as they choose their own partners. This may lead to self destructive choices in partners. In other cases, of course, they can learn from their parent’s mistakes and end up with good marriages.

I also don’t know of any research that has been able to systematically study the effect on children growing up with parents who are unhappily married and resent their own decision to stay together for the children.

Role of Therapy

In the course of my psychiatry practice I have seen many women and men  over the years who were contemplating separation, divorce or had been through this process. While it is helpful to be familiar with the above and other writings, I have found that there are so many variables that it serves no value to generalize in regard to any individual in this situation. Each person brings his or her own history, background, values and emotional template and we must try our best to help them within this context.

One of the advantages to a person who chooses to get help at this cross road in their life is that we can determine if they have a specific psychiatric condition which if treated will make it much easier for them to negotiate this life crisis and make decisions. For example if a  person has an untreated mood disorder such as a major depression or a bipolar disorder there could be intense mood changes which are clouding or influencing their decision making processes. Much more complicated but quite relevant could be certain types of personality disorders or patterns which invariably lead an individual to make repetitive unsuccessful or even destructive choices in their lives. Ideally such a person will be able to enter into therapy for a reasonable amount of time before making important decisions which may be hard to reverse. As in most therapy situations, a good therapist will remain neutral, not let his or her own personal values unduly influence the patient while allowing an examination of the life crisis. One challenging situation which often requires an exception to this completely neutral stance is when the patient (most likely  a  women ) is the victim of clear repetitive physical abuse by her partner  and requires positive affirmative encouragement and support by the therapist on order to step away from it.

Conclusion

I believe “Loving Frank” is an excellent book. It not only tells the story of two very interesting people which ends with the  tragic death of one of them,  but it stimulates reflection on a whole myriad of personal issues which were as relevant 100 years ago as they are today.

I welcome your comments on this subject

Tomorrow: Will Psychiatrists do Psychotherapy?

The Happy 65^th Birthday Conversation

I remember the first time I had the “Happy 65^th birthday” conversation with a patient. He was a very successful businessman and financial investor whom I had first seen in my New York practice about 15 years previously at the time he was having some personal and business crises. He was in twice week  psychotherapy with me for about three years. When he was 62 his wife died and he came in for a few sessions during this difficult time but handled his grieving as well as could be expected. He came back to see me two years later related to conflicts within himself and with his children about a decision whether or not to get married to a women with whom he had a relationship for about 6 months. I saw him once per week and as I expected, he was working well in therapy.

Your Fee is Reduced

I knew his 65^th birthday was coming up and when he came in and announced it was his birthday I replied, “Happy Birthday and your present from me will be that your fee will be reduced 150% to about $100/session”. I elaborated that this was the Medicare fee for 45-50 minute psychotherapy sessions.  He laughed and said, “Of course not, I am more than glad to pay your full fee and you know that I have no trouble affording it.” He was quite surprised when I told him that would be against the law and that I was mandated to charge him the Medicare fee. He offered to pay the difference and thought it was grossly unfair to me for him to pay me a reduced fee. I told him that I had no choice and that the only way that I would be able to see him was to charge him only the Medicare allowable fee. Obviously, this became a topic in the therapy with him but that is not the point that I am discussing here.

Impact on the Psychiatrist of Treating Patients on Medicare

Over subsequent years as many of my patients aged, I had similar conversations with them. I had previously treated a relatively small number of patients on Medicare and was comfortable in accepting the reduced fees. While the fee for psychotherapy was much lower than my customary fee, the Medicare fee for psycho-pharmacology was only slightly below my usual fee and the time of these visits were 20-30 minutes per session. When I would see patients who had private insurance, most of their policies allowed them to see a doctor “out of network” which usually meant that the patient was allowed to make up the difference in payment of what their policy allowed for treatment and that of my usual fee.  I also had a major academic position so overall the Medicare portion of my income was relatively small.

While I could theoretically limit the number of patients that I would see on Medicare, I was not comfortable in choosing individual patients to treat using that criterion. Once I would agree to see a patient, as I stated above, I would be obligated to charge them only the Medicare fee. So as I always did,  I continued to accept Medicare patients as they came to me if I felt I could help them.

However, as the years progressed I was increasingly involved with other professional activities mainly research, special projects as well as eventually becoming the Speaker of the Assembly of the American Psychiatric Association. This meant that I had less time for private practice and therefore seeing patients on Medicare would have a more significant impact on my income.  There happened to be a brief period where I was not treating any patients on Medicare. Since it would not impact any of my current patients, at that point, I made a decision to do something that I thought I would never do. It was something that I understood an increasing number of psychiatrists and other doctors in New York, Washington D.C. Texas and I am sure other locations were doing.

The Opting Out Solution

I opted out of Medicare! This is a legal process where a doctor files papers with Medicare which states that he or she is no longer part of the Medicare program and can no longer submit bills to Medicare nor could any of his or patients submit your psychiatric bills to Medicare for reimbursement. In fact, patients had to sign a statement that they understood that neither they nor their heirs could be reimbursed for any bills that you had given them for treatment. I, of course could see any patient of Medicare age but they could only pay me out of pocket or be reimbursed through insurance that they might have other than Medicare. This worked satisfactorily for me as I had a limited private practice, which I also continued when I recently relocated to Southern California. I will always tell patients when they first call me for a consultation that I am no longer part of the Medicare program and the implications of this. Some find this O.K. and will see me while others will not.

I don’t believe that my particular decision to opt out or the decision of other psychiatrists to do likewise seriously impacted the availability of care in the two communities in New York and California where I practiced. As far as I could see, there still are sufficient psychiatrists accepting Medicare. Perhaps some were not offering psychotherapy to such patients but were there to do psycho-pharmacology, which is essential care for many conditions. Also, in these areas there are many psychologists and social workers who are trained in psychotherapy, many of whom have a fee schedule less than the prevailing psychiatric fees for psychotherapy. They often work in conjunction with a psychiatrist who prescribes medication. Such dual therapy, in my experience, usually works quite well. However, in some situations it is much more ideal that a psychiatrist should do the psychotherapy and prescribe the medication to an individual patient. If psychiatrists continue to opt out in these communities or in communities where there are limited psychiatrists, this could become a major problem.

Implications of New Changes in Our Healthcare System

We are on the verge of major changes in our healthcare system. Certainly I hope and expect that the coverage of mental illness will be on parity with other medical conditions. This should include inpatient treatment and outpatient follow-up care for serious mental illness, which includes substance abuse. It should also include psychiatric care for all designated mental conditions. It is possible that there will be limitations put on the number of sessions allowed for psychotherapy and on the fee schedules that are set up for this form of treatment. Ideally the fee schedule should be fair and equivalent to other medical care, based on the time that the psychiatrist spends administering psychotherapy for patients who need it. These are very complicated issues. While psychotherapy has been shown to be effective with evidence-based research, there may not be the same degree of established research as to the efficacy compared to some other medical conditions. This could lead to limitations or no reimbursement for psychotherapy of certain conditions. If the emerging system limits or  discourages psychiatrists from doing psychotherapy, this will be a great loss in providing mental health care in this country. The growth of psychotherapy has a history as coming from psychiatrists, along with our colleagues in the mental health field So many of the great therapists and teachers have been outstanding dedicated psychiatrists. If psychiatrists are forced to do less psychotherapy, there will be a diminution in training programs and psychotherapy research, which could be a great loss to the quality of care being delivered in this country.

I fervently hope that we make major changes in our healthcare system. I personally believe that there should be a public option even though I recognize the possible dilemma as I indicated above, that could occur for psychiatrists who wish to utilize their psychotherapy skills along with their other psychiatric treatment modalities. The best way to work this out is to continue to put a searchlight on all aspects of this issue. I hope that this piece will stimulate discussion that will allow us to continue to move forward and solve these problems.

Your comments are welcome.

About year ago we took a family vacation in San Francisco and I walked across the Golden Gate Bridge with my granddaughter who was just becoming an avid reader. At various intervals on the walk we encountered a  suicide hotline telephone and a sign which said There is Hope. Make the Call. The Consequences of Jumping From This Bridge are Fatal and Tragic. This put me in the difficult position of trying to explain to a seven year girl why people might want to kill themselves and why do they choose this bridge to do it.

I first encountered this special characteristic of this beautiful bridge during my rotating internship at San Francisco General Hospital  when I had the opportunity to examine would-be jumpers who were brought to the ER or to the Psychiatric Service. An update on knowledge known about this subject, some of which I will discuss in this blog, just came out in the October 2009 issue of the American Journal of Psychiatry in an article titled Suicide From the Golden Gate Bridge by Drs. Mel Blaustein and Anne Fleming.

It Wasn’t Suppose to be A Place For Suicide

In 1936, Chief Engineer Joseph Strauss wrote, The Golden Gate Bridge is practically suicide proof. Suicide from the bridge is neither possible nor probable. It turned out however that the Golden Gate Bridge is the most popular suicide site in the world. By 2008 it was calculated the number of suicidal deaths form this bridge was close to 2000.

The bridge is really quite an accessible site to someone determined to use it for suicide. It has a pedestrian walk, a four-foot railing, a bus stop and a parking lot.

What is the Attraction of This Bridge For Suicide?

It certainly is a beautiful bridge offering breathtaking views of San Francisco, Oakland, Berkeley, Alcatraz and the San Francisco-Oakland Bay Bridge as well as the Pacific Ocean. There is often a morning and evening mist. It may be the most photographed man-made structure in the world.

Between 2005 and 2008 Dr. Blaustein interviewed 63 people who had threatened to go to the bridge to commit suicide. 49 of them were male with a mean age of 38. The reasons that they gave for selecting the bridge included accessible/easy (N=36), romantic (N=15), painless (N=6), other reason (N=16). It is quite doubtful that it is painless. Jumpers fall over 200 feet and hit the water in 4 seconds at 75 mph. They die from massive injuries to the chest, heart, central nervous system (spine and brain) or by drowning. The fatality rate is 99%. One report of an interview of 6 of the survivors revealed that all of them said that their suicide plans involved only the Golden Gate Bridge.

People who commit suicide from the Golden Gate Bridge do not have a greater degree of mental illness than suicides in general. 40 % were under psychiatric care at the time of their deaths. 22% had made prior attempts and 25% had left suicide notes. The majority of them were believed to have been employed. Suicide jumpers at the Golden Gate Bridge according to the Blaustein & Flemming article come from all walks of life including a county medical society president, a pastor of a Lutheran church, a president of the Oakland Real Estate Board, the founder of Victoria’s Secret and the son of President Kennedy’s press secretary.

I use to think that San Francisco was a magnet for people from all over with problems and those who wanted a try a new lease on life. I had thought that perhaps suicide from the bridge might be more likely to occur in those who came there and still couldn’t deal with their problems. However it turns out that mostly local residents commit bridge suicides.  Only 5% of jumpers between 1995-2005 were non-Californians. Apparently there are similar statistics at Niagara Falls where during one time period the 141 people who committed suicide lived within a 10-mile radius of the Falls.

Will a Special Barrier at the Bridge Prevent Suicides?

Many people have wanted a barrier to be built at the Golden Gate Bridge to prevent people from jumping off the bridge. Barriers have been shown to reduce suicides at a given location. Barriers at the Eiffel tower, Empire State Building and the Harbor Bridge in Sydney, Australia have virtually eliminated suicides at these locations. However, clinicians have known that if people are determined to kill themselves, there is no foolproof method of stopping them from eventually carrying out this desire.

That being said, many studies have shown that reducing a lethal means can reduce suicide statistics. When non-lethal gas was substituted for coal gas, which was previously known to be the cause of 1/3 of suicides in England, the suicide rate fell 25%.  Building a suicidal barrier at the Duke Ellington Bridge in Washington D.C. reduced the number of suicides in a seven year period from twenty-three to one. The suicide rate from the nearby Taft bridge that doesn’t have a suicide barrier did not increase Similar examples are sited from Augusta, Maine, Bern, Switzerland and Bristol, England.

One study examined 515 people who were restrained by police or bridge workers from jumping off the Golden Gate Bridge between 1937-1971. As of 1978 94% either were still alive or had died of natural causes. Only 6 % were believed to have subsequently committed suicide.

Blaustein and Flemming in their excellent article offer some suggestions as to how a barrier at the Golden Gate Bridge might work to prevent suicide beside the obvious one of blocking access to a lethal method of killing oneself. They note that even if people were diverted to another method to attempt suicide, it is likely that such a method would be less lethal. They also discuss the theory that suicidal individuals may interpret a barrier as a “sign of care” and possibly reduce their despair. Finally they speculate that certain sites such as the Golden Gate Bridge may become suicide magnets and may even catalyze or amplify suicidal feeling in vulnerable individuals therefore a barrier at such a site could be effective in reducing suicides.

In October 2008 an effort by many organizations led by the Psychiatric Foundation of Northern California was successful in getting the Golden Gate Bridge Board to approve the construction of a suicide barrier. Environmental studies and a funding plan need to now be developed before it can be built.

Understanding Suicidal Behavior and Preventing It

Psychiatrists and other mental health professionals have been studying suicide for many years with the hope that the more we understand it, the better that we will be in treating suicidal people and preventing suicide. We believe that the treatment of depression with medication, psychotherapy and often in combination is probably one of the more effective deterrents to suicide.

Research has shown that there are biochemical differences in various parts of the brain in people who become suicidal. There also has been evidence that higher levels of impulsive aggression in individual as well as a family history of suicidal behavior appear to be predictors of suicidal behavior in individuals. These characteristics are not simply explained by the presence of depression. It also has been shown that a history of childhood sexual abuse can be associated with subsequent suicidal behavior as an adult.

Do Ask and Do Tell !

Mental Health professionals know that one of the best methods of determining if someone might be suicidal is to ask them. It is a misconception that when a caring person inquires about suicidal thoughts, this will somehow give a person this idea or intensify any such tendency. Much more likely, the presence of someone who cares enough to ask them will make it possible to get that person to accept help.

We know that people who are depressed do come out of this bleak mood. Not only does the support of others make a difference but also treatment for depression does work. This is why the irreversible act of suicide is all the more tragic. Perhaps this is best illustrated by the words of one of the few people who survived a jump off the Golden Gate Bridge as reported by Blaustein and Flemming in the American Journal of Psychiatry.

I just looked out over the water to the city and it was beautiful. I felt that this was the right time and place to kill myself. The last thing I saw leave the bridge was my hands. It was at that time that I realized what a stupid thing I was doing and there was nothing I could do but fall. The next things I knew I was in the water hoping that someone would save me saying, “Please God, save me, somebody save me.” It was incredible how quickly I had decided that I wanted to live once I realized everything that I was going to lose, my wife, my daughter, the rest of my family.

This man is currently in his 30th year of marriage. He is a high school teacher and part time coach. His daughter is an elementary school teacher.

Your comments are welcome.

New York Times Front Page Article About Depression and Suicide in the Military Goes too Far by Publishing Confidential Mental Health Records

After Combat, Victims of an Inner War by Erica Goode was an outstanding front page description of depression and suicide in the military in the NY Times on Sunday August 2, 2009. It focused on the background and circumstances of the suicide of Sgt. Jacob Blaylock who was one of four soldiers of a 175 person military unit who ended their own lives. It used his case history to humanize the complicated issues involved in screening for mental health problems and providing treatment for military personnel who need it. Ms Goode gathered information from many sources including friends, families, fellow soldiers, and records of military service as well as treatment records in the veterans health system. However, I question whether this article, as written, should have been published as it has obviously included publication of confidential mental health records.

The article states that veterans agency records obtained by the New York Times reported that Sergeant Blaylock was hospitalized for depression during a previous tour of duty. It quotes from mental health records from a veterans affairs medical center that he had told an intake counselor that he was experiencing ” sleep problems”, “excessive worry and anxiety,” “recurrent thoughts of death ” and other symptoms. It states that he answered” yes” to all four screening questions for post-traumatic stress disorder” and goes on to describe the content of what appears to have been a therapy session. There are other examples in the article of how the patient responded to being evaluated for suicidal ideation as well as a description of the psychotropic medications which were prescribed for him. Ironically, this is followed by a statement from a spokeswoman for the veterans agency noting that it could not legally comment on specific cases without family authorizations which would seem to indicate that the surviving family did not provide the medical records which they may have obtained. Even if they had, this would be a questionable journalistic approach.

The New York Times owes the mental health community and the public at large an explanation as to the ethical standards that it uses

The delineation of the difficulty in predicting suicidal behavior, the need for more research and continued development of screening and treatment programs can be a worthy outcome of the publication of this article. On the other hand the exposing of confidential medical records may very well make potential patients of the military and veterans system hesitate to seek care as the word gets out that their records can end up in the hands of the press. I believe that the New York Times owes the mental health community and the public at large an explanation as to the ethical standards that it uses in situations such as this one.

I sent my above comments to the NY Times as a letter to the editor and as an inquiry to the public editor who solicits concerns about the paper’s journalistic integrity. As of this date I have not received any acknowledgment or reply.

This blog however gives me the opportunity to raise this issue with my colleagues in the mental health profession and all interested parties. Even in the pursuit of a worthwhile goal of improving mental health services and preventing future suicides, was it necessary to obtain confidential medical records of this nature and display it on the front page of one of the leading newspaper in the country? Could not the same effect have been achieved by printing the interviews with the various parties and conveying the dramatic and sad story without resorting to this last step? If there are no journalistic standards or ethics in this regard, does this mean that any medical records that a reporter can get his or her hands on are fair game for publication if the reporter and the editor feel the story is worthwhile? Or is up to their judgment as to what part of the record can be published? If this becomes the standard of our leading newspapers, I hope that this will not erode the confidence and trust that is necessary for psychiatric patients to have in the professionals who care for them and in the hospitals where it sometimes becomes necessary for them to be admitted.

I welcome your comments on this subject.

Fox TV Program MENTAL about a  psychiatrist is not an authentic  portrayal of a real shrink

As someone who wants to see the public educated about  psychiatry and mental health, I was hopeful that Fox’s new TV series MENTAL would achieve   the impact and success that Fox’s other series HOUSE has accomplished. Unfortunately after viewing the first 4 out of the projected summer series of 13 episodes, I am quite disappointed.

Actor Chris Vance

The star of the series is Dr. Jack Gallagher (played by Chris Vance). He is a young, likeable, very smart doctor who is the new Director of Mental Health Services at a Los Angeles hospital ( so far so good ). However, his method of operating doesn’t resemble any real psychiatrist I have ever known or heard about. For example, we are introduced to the main character when he walks into the Emergency Room of his new job and sees a psychotic paranoid man without any clothes menacing everyone. Dr. Gallagher takes off all his own clothes in order to better relate to the patient and talks him down. Not only would a real psychiatrist never do this but even a first year resident should know that such behavior would be viewed as an extremely frightening threat by a patient in this situation.  In one episode Dr. Gallagher is treating a celebrity patient with a Narcissistic Personality and some breaks with reality. The doctor invites a good friend of the patient to view the therapy sessions with the patient through a one way mirror breaking all ethics of confidentiality which are important in all of medicine, especially in psychiatry. In still another episode, a women prosecutor is racked with guilt about people she has convicted. The treatment consists of the hospital staff pretending to be players in a court room drama which the patient thinks is really happening. They plan on reenacting the drama until the patient has somehow worked through her problem. The twists and turns of the various plots appear to be those that people might fantasize that a brilliant psychiatrist in this setting might do, but lack authenticity which would make it much more interesting.

I understand that a successful TV program has to use imagination and take poetic license in its writing. The long-running show ER certainly had complicated character developments and some fanciful plots. However the medical aspects of the program were quite realistic which was an important part of the great appeal of the program. In fact, I believe that one of the reasons that medical students over the past several years have been increasingly choosing emergency medicine as their specialty is because these doctor characters became role models for them. The popular TV show HOUSE showed an eccentric physician with his own quirks but nevertheless just about all the cases were based on scientific thinking and good medicine which also was riveting TV.

It appears to me that the producers and writers of MENTAL either did not have psychiatric consultants or were not listening to them. I know of medical students or medical residents being assigned viewing of ER or HOUSE episodes whereas I can’t imagine asking a trainee to view MENTAL unless it is to see what they should not do. Truth can be more interesting than fiction and there are plenty of clinical books and articles which describe case histories which will make great material for a television shown such as MENTAL.

The National Alliance on Mental Illness (NAMI ) has this show on it’s StigmaBusters alert which means members of this group will be watching and making judgments as to how this program depicts mental illness. Thus far their few comments are mixed. . I certainly share their hope that television shows such as this one will give truthful awareness of mental illness and the battle that patients, families and healthcare providers are going through on the road to recovery. I will be following future episodes to see if they get it right.

Addendum:

I caught some additional programs and I regret to say, in my opinion, the program is not on track to depict mental illness or psychiatry in any where near a realistic or interesting manner. For example one program suggested that a patient’s belief in reincarnation and past lives has somehow connected him to a man who was the lone survivor of a mine disaster almost 100 years ago. Although the psychiatrist in the show says he doesn’t believe in such things, the patient’s belief somehow gave him knowledge of factual things he otherwise couldn’t have known and leads to him having physical symptoms including an episode of a fever of 106 degrees. Even as a far fetched fanciful tale, the story fell flat and it certainly is a big disappointment if it is trying to demonstrate how modern day psychiatrists practice. I can only hope that if this show is renewed and given a second chance next season, the writers will take a close look at some real case histories, which are readily available in textbooks and journals, although perhaps disguised for confidentiality reasons. They will find that truth is stranger and more fascinating that totally made up fiction and that may even help with the all important ratings.

Second Addendum- Program Still Out of Touch with Reality

Since I was a little delayed in launching this first edition of the PsychiatryTalk blog I can report on the season’s two hour finale. Jack hospitalizes his long lost schizophrenic sister and makes the unorthodox and usually unethical decision to try to treat her himself.  He realizes that he was emotionally too involved to be objective and takes the advice given to him and gets some therapy for himself. During a therapy session we  get a glimpse that  one of his problems is that he is afraid of having a psychotic episode himself although he acknowledges that the onset of this condition at his age would be unusual. After a few therapy sessions where we only heard the voice of his therapist, we finally see that his therapist was actually himself . He was really just privately reflecting on things! During the  two hour finale we are also shown two patients with very rare but quite interesting real psychiatric conditions which I will give the program credit for introducing to the audience. One is a man who since childhood has had an intense desire to ampute his own hand. He does it and ends up in the hospital,  Jack recognizes the condition and distinguishes it from the more common type of psychosis. The second patient believes that he has been transformed into a werewolf and is about to kill others seeking blood when the moon comes up. He is holding Jack and some staff members hostage with a gun. Jack convinces the man to bite his arm so they both can face the moonrise together and whatever it will bring. The first season ends with Jack having quit his job at the hospital and is basically going off into the sunset with his guitar case on his back.If this program is renewed, it is hard for me to believe that they will top this season in so far as showing a more unrealistic picture as to what the treatment of mental illness is about . If they should have a second chance,  I sincerely hope that they will give Chris Vance, the talented actor who plays Dr. Gallagher, some better scripts. But of course first they will have to rehire the good doctor.